MSK Revision 2 Flashcards
Describe what is meant by De Quervain’s tenosynovitis [1]
Which tendons does it most commonly affect? [2]
De Quervain’s tenosynovitis is a condition where there is swelling and inflammation of the tendon sheaths in the wrist. It is a type of repetitive strain injury
It primarily affects two tendons:
Abductor pollicis longus (APL) tendon
Extensor pollicis brevis (EPB) tendon
Describe the presentation of DQT [3]
Pain at the base of the thumb, which can extend to the forearm
Pain exacerbation during thumb abduction, gripping, or ulnar movement of the wrist
Tenderness of the anatomical snuffbox
Name and describe the test used for DQT [1]
Finkelstein’s test:
- Finkelstein’s test involves the patient making a fist with their thumb inside their fingers.
- Then, the wrist is adducted (ulnar deviation), causing strain on the APL and EPB tendons.
- If this movement causes pain at the radial aspect of the wrist, the test is positive, indicating De Quervain’s tenosynovitis.
Mangement for DQT? [3]
Non-operative:
First line:
- NSAIDS, rest and immobilisation with a splint
Second line:
- steroid injection
Operative:
- surgical release of 1st dorsal compartment (radial based incision proximal to the wrist)
Define trigger finger [1]
What is trigger finger AKA? [1]
It is also known as stenosing tenosynovitis.
Describe the pathophysiology of trigger finger [2]
Normal physiology:
- Flexor tendons of fingers pass through sheaths along the length of the fingers
Trigger finger:
- Get thickening of tendon or tightening of the sheath
- Means when flexed / extended it causes pain, stiffness or catching
- This spefically happens at the first annular pulley (A1) at the metacarpophalangeal (MCP) joint.
Clinical presentation of trigger finger? [3]
Presentation:
- Is painful and tender (usually around the MCP joint on the palm-side of the hand)
- swelling around MCP joint
* Does not move smoothly
* Makes a popping or clicking sound - hallmark feature
* Gets stuck in a flexed position
Which patient populations have a higher chance of getting trigger finger? [4]
DMT1
RA
gout
carpal tunnel syndrome
Non-operative [2] and operative treatment of trigger finger? [1]
Non-operative:
First line:
- splinting, activity modification, NSAIDs
Second line:
- Steroid injections
Operative:
- Surgery to release the A1 pulley - either percutaneous release or open release
Define Dupuytren’s contracture [1]
Describe the pathophysiology [2]
Dupuytren’s contracture is a condition where the fascia of the hand becomes thickened and tight, leading to finger contractures.
Pathophysiology:
* The palmar fascia of the hand forms a triangle of strong connective tissue on the palm.
- the fascia of the hands becomes thicker and tighter and develops nodules as a result of excessive collagen deposition
- Cords of dense connective tissue can extend into the fingers, pulling the fingers into flexion and restricting their ability to extend (contracture).
Describe the presentation of Dupuytren’s contracture [3]
- First sign: hard nodules on the palm.
- Skin thickening and pitting
- Finger pulled into flexion
- Most commonly the ring finger affected
Describe a test used to assess for DC [1]
Table-top test:
- The patient tries to position their hands flat on a table. If the hand cannot rest completely flat, the test is positive,
At what stage do you consider surgical treatment for DC? [1]
consider surgical treatment of Dupuytren’s contracture:
- metacarpophalangeal joints cannot be straightened and thus the hand cannot be placed flat on the table (positive table top test)
What are the three options for surgery for DC? [3]
Needle fasciotomy
- (also known as needle aponeurotomy) involves inserting a needle through the skin to divide and loosen the cord that is causing the contracture.
Limited fasciectomy:
- involves removing the abnormal fascia and cord to release the contracture.
Dermofasciectomy:
- involves removing the abnormal fascia and cord, as well as the associated skin. A skin graft is used to replace the removed skin.
The median nerve supplies the motor function to the three thenar muscles. These muscles make up the muscular bulge at the base of the thumb that is responsible for thumb movements.
Which muscles are these? [3]
Which movements do they cause? [3]
Abductor pollicis brevis (thumb abduction)
Opponens pollicis (thumb opposition – reaching across the palm to touch the tips of the fingers)
Flexor pollicis brevis (thumb flexion)
NB: The other muscle that controls thumb movement is the adductor pollicis (thumb adduction). However, this is innervated by the ulnar nerve. Whether this is classed as one of the thenar muscles depends on where you look.
Firm and well-circumscribed mass that transilluminates on the dorsal aspect of the wrist → []
Firm and well-circumscribed mass that transilluminates on the dorsal aspect of the wrist → ganglion
NB: While fibromas are usually well-defined and firm, they do not transilluminate
*
What are the four rotator cuff muscles? [4]
What movements do they cause? [4]
S – Supraspinatus – abducts the arm (first 20/30 degrees)
I– Infraspinatus – externally rotates the arm
T – Teres minor – externally rotates the arm
S – Subscapularis – internally rotates the arm
Describe the difference between intrinsic tendon degeneration versus impingement syndrome in rotator cuff injuries
Intrinsic tendon degeneration
* Tendon hypo-perfusion of a watershed area
* Repetitive micro-trauma
Impingement syndrome can be classified as external, internal or secondary:
External
* Compression of rotator cuff tendons as they pass underneath the coracoacromial arch
* Narrowing of this space can occur due to osteophyte formation, bony spurs or malunion after fractures
Internal
* Associated with overhead and throwing sports activities causing small repetitive injuries
* Under surface fraying of infraspinatus tendon on the posterior glenoid
* Increased association with labral disorders
Secondary
* Glenohumeral instability leads to slight humeral head subluxation
* This narrows the acromiohumeral interval
Describe the symptoms of the following with subacromial impingement symptoms (SAIS) or symptoms of a torn rotator cuff tendon
subacromial impingement symptoms (SAIS):
- Pain (79%) typically localised to the anterior superior shoulder / deltoid region
- Worse at night and at rest; worse laying on it
- True shoulder weakness is typically NOT present in SIS unless the patient has progressed to having a significant rotator cuff tear. However, significant pain may cause symptoms similar to weakness.
- Painful arc of motion - during arm abduction, shoulder pain occurs between 60 to 120º; eases beyond 120
Torn rotator cuff tendon:
- Pain is the most commonly reported symptom (83%)
- Muscular weakness and atrophy (50-63%)
- Inability to abduct the arm above 90º
In those with suspected SAIS, two common examination signs can be elicited
What are they? [2]
Neer’s impingement test
* Anterolateral shoulder pain reported during forward flexion with arm internally rotated
Hawkin’s test
Forced internal rotation of an arm held at shoulder height and elbow bent at 90º causes anterolateral shoulder pain
In those with suspected rotator cuff tendon tears, three common examination signs can be elicited
What are they? [3]
‘Empty can test’
* Evaluates supraspinatus
* Patient’s raise their arm to 90º in the scapular plane
* The arm is internally rotated (thumbs down)
* Downward pressure is applied to their arm
* Presence of weakness or pain indicates a tear
Posterior cuff test
* Evaluates infraspinatus
* Weakness or pain on resisted external rotation suggests a tear
Gerber’s lift-off test
* Evaluates subscapularis
* Patient attempts to lift a hand from small of the back, while resistance is applied
* Weakness or pain suggests a subscapularis tear
Describe the pathophysiology of frozen shoulder [1]
The glenohumeral joint is the ball and socket joint in the shoulder. The glenohumeral joint is surrounded by connective tissue that forms the joint capsule.
In adhesive capsulitis, inflammation and fibrosis in the joint capsule lead to adhesions (scar tissue). The adhesions bind the capsule and cause it to tighten around the joint, restrict movement in the joint.
Get three stages (probs dont need to know)
1. Freezing Phase: synovitis leads to increased vascular permeability, resulting in capsular oedema, pain, and reduced range of motion (ROM). Progressive fibrosis and angiogenesis and nerve growth occur
2. Frozen Phase: Characterised by the progressive loss of glenohumeral movements due to a stiffened capsule.
3. Thawing Phase: This phase involves the gradual resolution of symptoms
Describe the clinical presentation of adhesive capsulitis [4]
Course of symptoms:
Painful phase
– shoulder pain is often the first symptom and often worse at night
Stiff phase
– shoulder stiffness develops and affects both active and passive movement (external rotation is the most affected) – the pain settles during this phase
Thawing phase
– there is a gradual improvement in stiffness and a return to normal
Symptoms
* external rotation is affected more than internal rotation or abduction
* both active and passive movement are affected
* the episode typically lasts between 6 months and 2 years
Describe shoulder anatomy that prediposes impingement syndrome [3]
Impingement syndrome is caused by rotator cuff tendonitis as the tendons pass beneath the acromion. The supraspinatus muscle’s tendon is most commonly affected.
Patients with impingement syndrome often complain of pain when their arms are raised (this is particularly common in mechanics and manual labourers who work with their arms overhead).
When the arm is raised, the subacromial space narrows, which can result in impingement of the supraspinatus muscle tendon leading to an inflammatory response.
